Non-compliance follow-up·September 25, 2025

Unannounced case management visit made out to this facility today by Licensing Program Analyst (LPA) Charlie Yang and Licensing Program Manager (LPM) Liza King, who were met by the facility Health and Wellness Director Afifa Kahn and Memory Care Director Jocelyn Ning and the purpose of the visit was explained. The designated Administrator Andrea Armstrong arrived at 9am. Current census was 92 residents, of which 27 resided in the memory care unit also referred to as Traditions. Currently there are 8 persons receiving hospice care, no residents require a hoyer lift. The purpose of this case management visit was to conduct a quarterly visit as outlined from the Non Compliance Conference held on 03/25/2024 and the requirement to have increased monitoring at that time. The focus of this quarterly visit was to review the following items that were initially brought forth on 03/25/2024: Medication Errors addressed in report Staffing Concerns addressed in report Reporting Requirements addressed in report Medication Training past 3 months has been sent via email to Charlie.Yang@dss.ca.gov for review Facility Polices Regarding: Assessments, Monitoring of Residents, Change in Condition, Medication Errors - any inservices related to the above over the pst 3 months to be sent via email to Charlie.Yang@dss.ca.gov for review cont. A tour of the Traditions neighborhood was conducted. LPM King observed breakfast meal service consisting of eggs, bacon, sausage, pancakes and cereal. Residents appeared groomed and ready for the day. LPM verified doors that required to be secured were, the area appeared clean with no presense of odor. A tour of all hospice rooms in the Traditions area was conducted as well as well as 4 additional rooms. Rooms were clean without clutter or odor, no toxins were present. Staff consisted of a Memory Care Director, three caregivers, one housekeeper and one medtech in the Traditions area upon arrival. Interview confirmed this is usual staffing except on weekends when there are one additional caregiver on each shift in case of call offs. A copy of the Aug schedule and hours worked log was requested for review. The schedule shows 3 care givers and 1 medtech scheduled both AM and PM shift and 1 caregiver and 1 medtech for the overnight shift. According to interview with staff there are 10 residents in the Traditions area that require 2 person assistance. According to interview with the Administrator although this is a preference of staff there are 4 careplans that require 2 person assistance, the Health and Wellness Director confirmed this. Staff schedule for the month of Aug was reviewed. Staff hours worked during the month of Aug were reviewed. On one of four days reviewed during the month of Aug care staff were 2 for am and 2 for pm shifts. Admin reported that when there is a shortage of care staff then the Memory Care Director is to provide assistance with care on the floor. During the visit, the care logs were not verified to show if the MCD provided care. This will be looked at on a future visit. Based on the staff schedule there is one CG on NOCs and one Med Tech assigned to the Traditions area. Per interview with the Admin the caregiver from the Asissted Living side is called to the Traditions area to assist when needed. Additionally, the MedTech is available to assist with care. Lunch meal service was observed. The shower log was reviewed for the current month which showed one missed shower (resident refused). ADL logs were reviewed for AM, PM and overnight shifts for the month of September which document dressing, bathing, grooming toileting and transfer assistance all being provided. cont. Four resident files were reviewed as a result of incident reports received in the Regional Office (RO). R1 sustained 5 falls over the past 3 months. The RO received 2 IRs for the month of September. Fax conformation was provided for falls that occurred during July and Aug. All care plans were updated. R2 remains out of the community and further follow up is necessary. For R3 the RO is requesting the facility obtain the Death Certificate and forward it to the RO. Additional follow up may be necessary. IR received in the RO for the incident. R4 5 IRs related to falls were provided while at the facility for the months of July, Aug, and September. During a file review the LPM revealed 3 additional falls during the month of Aug. According to the Admin falls without injury or ER visit do not result in an incident report being submitted to the RO. Based on documentation the resident has fallen 8 times over the review period. The Care Plan was updated one time dated 08/25/2025. Per conversation with Admin no additional interventions are needed at this time. The RO received one incident report. Fax confirmation was provided at todays visit for the additional IRs. LPM reviewed the Physicians orders and MARS for the months of July, Aug and September for four residents in Traditions (R6, R7, R8, R9). Prn medication provided and effectiveness were documented. R6 all medications were signed off. R7 medications were not signed of for the PM on 08/02/2025, incident was reported to the RO, no other missed medications. R8 PM medications missed on 08/02/25 and reported to the RO. Additionally, melatonin missed on 08/03 and 08/04, breathing treatment was missed on 08/16 due to facility awaiting Rx to be delivered. Again, this occurred on 09/06, 9/23, 09/24 and 09/25; medications pending refill delivery. R9 no missed medications. Technical Assistance was provided as 3 of 4 resident Centrally Stored logs were not completed. LPM reviewed Controlled Substance logs which were complete, 12 bottles pulled and compared to the Centrally stored log and 5 counts were completed with no concerns noted. A follow up visit will occur at a later date to review Centrally Stored logs again. Citations were issued today in relation to a complaint received regarding mismanagement of medications. The findings from todays visit are being incorporated into that finding. NO citations are being issued as a result of this visit. An Exit interview was conducted with Andrea Armstrong, Afifa Kahn and Jocelyn Ning and a copy of the report was provided.